Dr. Urvi A. Shah: Hi, everyone, welcome to the Facebook live event for Myeloma Action Month. I'm Urvi Shah, a hematologist and oncologist at Memorial Sloan Kettering Cancer Center, and I look forward to discussing nutrition with you for myeloma, and happy to take questions eventually, once we have a few more people join. I see Sylvia has joined. Hello, nice to see you. Hi, Daria. Joanne, you're from Puerto Rico? That's great. We like to have people come from all over and join us. Peter, thank you for joining, as well, and appreciate your support for this.

It's great, we have quite a few people joining, so we'll get a few more minutes, let enough people join so we can then take questions. Hi, Nicola, from New Zealand, great to see you again, and hi, Frank. If you could put in the chat where you are from, too, sometimes that'll help. I see we have people from Washington State, Stacy from Cleveland, Stella from New Jersey, Debbie from Washington. Hi, Alana, great to see you, as well. Wow, we have people from Canada joining, as well, so a lot of people all over.

And this just goes to show how important this topic is to patients and caregivers and all of us. And we want to take care of the patient with looking at nutrition and a holistic approach, with, of course, regular therapy, but how do we also manage things beyond that? So maybe we'll take a couple more minutes, I see we have about over 60 people joined now, it's close to 70. Hi, Pete, from New Zealand, and I see Frank and Debbie, great to see you, and hi, Natalie.

So I wanted to take a minute, maybe, to introduce myself and talk about the topic. So I'm Urvi Shah, a hematologist and oncologist at the Memorial Sloan Kettering Cancer Center, and my research focus is looking at modifiable risk factors, so how does obesity, diabetes, diet, nutrition, the microbiome, all of these factors play into the immune system and cancer development and progression, and is there some things that we could do, small changes in our life that may help with improving outcomes once we have cancer, or preventing cancer if we're in a precursor state?

And I'm here to talk pretty much about who is nutrition important for, what is nutrition, when should we think about it, why and how, and maybe some practical tips. So I'm happy to answer any of these questions, and as we start, I'm also thrilled to say that this is Myeloma Action Month, but it's also National Nutrition Month, so it's a really good time to be looking at both these things simultaneously, and the best time to be discussing this together. And every March, we urge you to champion Myeloma Action Month to make an impact, and you can go to the website, myelomaactionmonth.org, as well, to get more information. And do put in questions in the chat, and we can think about discussing them together in the next 30 minutes.

I do see that there have been some questions around, what's the importance of nutrition, and does it really matter? And I think that hopefully, in these next 30 minutes, I can convince you that it's important, and we have to also think about where we are coming from. Are we just diagnosed with cancer, very overwhelmed with the treatment? Is there a lot going on, or are we already pretty healthy in what we eat and do that it doesn't matter? So it has to be individualized to each person. And we're not here to say that every person needs to make drastic changes once they're diagnosed, and then get stressed out about that and really not be eating well because they're making these changes that are drastic. But we want to think about what would be a way to maybe gradually make changes that are sustainable and long-term that actually can improve overall quality of life and health for patients.

So I see a question, what is your opinion on the assurance and purity and strength of supplements in light of less regulation? And that's a very important question, and let's talk a little bit about supplements. So I know that we all want an easy fix, or something that can fix or take care of the cancer which is natural and doesn't have much side effects. And it would be really great if there was one such miracle cure or supplement that did that. Unfortunately, the supplement industry, because it's not as tightly regulated as the drug industry, often, there can be supplements where there could be side effects, or they haven't been studied exactly, so we don't know the doses, and drug interactions can take place, too. So it's really important, especially if you're on therapy, to be discussing supplements with your doctor and maybe the pharmacist at that site to make sure there aren't any interactions.

Also, many of us assume that just because it's a natural and it's a supplement, it means that it's completely without any side effects or healthy, but there have been some population larger studies showing that actually maybe Vitamin E, beta-carotene, some of these supplements may increase cancer risk, like lung cancer risk. So we want to, again, study this better and understand, and I don't think everybody should just, across the board, take supplements. Another thing is, you can go to the website called About Herbs, from Memorial Sloan Kettering Cancer Center, and there is a lot of detail on each kind of supplement and what's known, what it helps for, and what the side effects could be, and interactions. So that's a really good place if you are looking for information on supplements.

I see a question about the gut microbiome, and then I see a question about sugar, so maybe we'll do those two. Maple is asking, can you talk about the gut microbiome? And so, when we think about the microbiome, I think we are really very early in the stages of understanding it and scratching the surface. I think in the last few years, you've seen a lot of research coming out around the gut microbiome, but I think in the next decade, we're going to see a lot more around this. And some things to think about when you are looking at the gut microbiome is understanding, what are all these studies showing, what is the general pattern? Because if we try to focus on one bug or one species, it can get overwhelming, and we're like, okay, how do we understand, this bug is associated with this, but another bug is associated with something?

So one of the healthier patterns and things we've seen in most studies is a concept called gut microbiome diversity. And the gut microbiome is bacteria that live inside of us, and we are actually more gut microbial cells than human cells. If you actually look at the number, we are about 38 trillion bacterial or microbial cells and 30 trillion human cells. It's just that the human cells are larger, so that's what you see, but it's important to be feeding what the microbial cells want to, and fiber is basically food for the gut microbiome.

What we do know is, gut microbiome diversity, more diverse the microbiome, the healthier. And think about this as a rainforest. So a rainforest has so many different species of birds, animals, plants, that's a healthy environment. Compare to that a plantation, only bananas, or any specific plant, and you've taken away the diversity of that ecosystem, and that makes it unhealthy or unsustainable as a long-term outcome.

So it's important to have an overall healthy microbiome when we're thinking about the diversity. How do we keep a diverse microbiome? And that's a lot of the research, because just now, a lot of the studies have looked more in cancer. Does gut microbiome diversity associate with progression-free survival? Does it associate with overall survival? Are we seeing any of this? And we actually are seeing, very consistently, whether it's myeloma, whether it's lymphoma, other cancers, too, post-transplant and myeloma, that higher gut microbiome diversity is associated with longer progression-free survival and overall survival.

But now the question is, how do we modulate gut microbiome diversity, and is it possible? So our NUTRIVENTION pilot study completed, and we're in the process of getting together and writing up the paper. And in that study, we helped patients eat more fiber-rich, plant-based foods, and what we did see is, actually, the gut microbiome diversity improved. And we did this intervention for three months, but we see even a year out, because they've made these changes gradually, and now are sustaining them, even a year out, we're seeing higher diversity.

So when you think about it, when you're making changes, one study of over 10,000 healthy individuals looked at whose gut microbiome is healthier, and they found that people who eat more than 30 types of plant foods per week actually have a healthier gut microbiome than if they eat less than 10. And what I'm trying to say with this is, having more of different types of plant foods and not just one. So if you're thinking about broccoli, or not eating broccoli every day, but eating broccoli, beans, collard greens, other things, and those herbs, spices, all of those count in the 30 plant foods.

So let's go to the next question, how bad is sugar, really? And that is a good question. What we do know is that most of the US population, not just the US, the world, is taking in way more sugar than what is the guidelines or the recommendations. So the average intake of sugar for the US population is about 17 to 19 teaspoons per day, 17 teaspoons, and one teaspoon is about three to four grams of sugar. So if you just think about the number, that is a lot, and that's where half the average population is, so a lot of the population is over half of that.

And if you look at one can of Cola or Coke, we'll have about 8 to 10 teaspoons of sugar, so one can can already raise the sugar intake. So when we think about how bad is sugar, understanding that sugar intake ... There's a difference in when we think about carbohydrates. So carbohydrates, you have the refined carbohydrates, and you have the complex carbohydrates. Complex carbohydrates are things like whole grains, which also have fiber, vitamins, minerals, protein, all of that, and they're very healthy. Whole grains have been associated with reduced cancer risk in multiple population studies given. So there are a lot of health benefits, and the guidelines recommend about three servings of whole grains a day.

However, within carbohydrates, you have the refined carbohydrates, or sugar, which would be white flour, sugar, sweetened beverages, candy, cakes, cookies, all of that. And that is a very different part, and it does not have the fiber, it can raise sugar or spike the sugar. So high sugar can lead to more insulin spikes, and insulin levels are associated with risk of cancer and progression. So in general, I would say cutting out sugar, which is unnecessary, is preferable.

Of course, if that's something that makes you happy, or very important for you to have a little bit of in a day. I'm not saying we want to be completely ... It's very hard to be maybe completely, but try to limit sugar intake to maybe seven to nine teaspoons per day, and that's kind of the recommended guidelines. So maybe think about looking at your diet and counting the number of teaspoons you might be taking in. A lot of sugar is hidden in cereals and cookies and things, so sometimes you don't even realize you're taking in a lot of sugar. So it might be worth actually just sitting down with what you eat typically and seeing how many teaspoons of sugar you get.

Other questions. So sugar substitutes, also, there is a little bit of mixed data around it. The International Agency for Research on Cancer have said that some sugar, artificial sweetener, is actually associated with increased risk of cancer. And when we studied this for MGUS, so the pre-cancerous state, monoclonal gammopathy, we did see an increased risk with sugar sweetened and artificially sweetened beverages, and the risk of MGUS development. So in general, I wouldn't say that sugar substitutes are that much healthier, just limiting it is preferable, if possible.

Other questions we have, one is, what are the best anti-inflammatory foods to incorporate in your diet? And that's a good question, and I think that many times, people want to know, what's that one food that could be the most healthy, or one thing? And like I said, I don't believe that there is only one healthy food that's important, but it is important to get enough fiber in your diet, and fiber-rich diets have been linked to actually more diversity and less inflammation. So we have seen reduction in inflammation in our NUTRIVENTION studies with eating more fiber-rich plant foods. A study from Stanford had actually looked at, patients were asked to eat fermented foods, and looked to see if there's a change in inflammation and the immune system, and they did show that eating more fermented foods reduces inflammation, as well.

Somebody is asking about maple syrup. So maple syrup is still sugar, whether it's maple syrup or beet-related sugars. If it is sugar ... Sugar can come in many forms. I encourage you to google different forms of sugar, and you will see that sugar can come in many names, and it's hidden, so people assume that because I'm having a particular kind of sugar, it's healthier because it's mung fruit or something, but in the end, this is all sugar. Is there a connection between myeloma, MGUS, and lupus? There is a connection between autoimmune disorders and myeloma and MGUS in population studies where there's a slightly increased risk, so it is possible. Fresh fruit is very different than what we would talk about in refined sugars, again, without the fiber. Fresh fruit is something I would encourage you to have a few servings a day. It's part of a healthy diet, and has lots more than just the sugar, because the sugar comes coated with the fiber and other phytochemicals and anti-inflammatory and antioxidant molecules, so that's quite important, too.

We have a question about, how do you avoid heme iron to starve cancer? And food, it requires to survive and grow. So heme iron generally comes from foods such as red meat and animal-based foods. Usually, the iron content in that is the heme iron. Plant foods also have iron, but it's usually the non-heme iron, which is considered to be less inflammatory. So again, there's not too much data around this to say that definitely, you want to limit it, but the heme iron, because it is inflammatory through many different mechanisms, if you really wanted to reduce that, then shifting your protein intake and things to beans, nuts, seeds, where you get some iron, but it's also the non-heme iron, will be a preferential way to do this.

Frank's asking, can exercise and protein drinks increase your creatinine? Protein drinks, yes, it can. High protein diets are associated with a slightly increased creatinine. The National Kidney Foundation has good guidelines on healthy diets for kidney disease, and recently, the American Journal of Kidney Disease put out guidelines for nutrition, and talked about the importance of eating fiber-rich plant foods for a healthy diet with kidney disease. And the reason for this is because plant foods, the protein in that tends to be a lower amount or less stressful on the kidneys, and much easier to handle in someone with advanced kidney disease. So that's something to again consider.

Sally's asking about turmeric, and I know lots of patients take this, and it's an important question to answer, does turmeric really help? In theory, turmeric has anti-inflammatory properties, and there is evidence for arthritis and inflammation, that it may help. There has been one study done from Australia looking at turmeric for smouldering myeloma, and they have published after that study, some case reports suggesting that some patients that took turmeric for a very long time had stabilization, or maybe even decrease in their disease ... Like, M spike trajectory. But these are all case reports and small numbers of cases.

We are trying to study this with the NUTRIVENTION-3 trial, which is currently enrolling at MSK, and also, the NUTRIVENTION-2 trial, which is enrolling, too. Hopefully, in the next few years, we'll have more data and answers to give you. At this time, because turmeric can also be expensive for patients to take every month, I think the data is limited, and so, patients need to decide for themselves whether it's worth it. With the study we are doing, we're going to try to get a deep dive into understanding its effects on the microbiome in myeloma and smouldering myeloma, and also on other inflammation markers and the immune system.

This is a good question, Katia is asking about diet to increase platelets and hemoglobin, and I know this is a big challenge for patients [inaudible 00:20:32], and I know that's hard. The unfortunate thing is, often in myeloma, the low blood counts are related to the therapy or the disease, and if it is not related to a nutritional deficiency, having more iron intake, or things like that. Many people think that if they're anemic, they need to take in more red meat, but that's not going to fix the problem if the problem is not because of iron deficiency.

And low iron, one way to check ... So if somebody's hemoglobin is low, post any therapy, and it's not improving, it's really important to ask your doctor, and I'm sure most doctors would do this, is check labs for anemia, vitamin B12, folic acid, other reasons why there might be anemia. Is it related to kidney disease? Is it, the blood cells are breaking down, or the bone marrow is not making enough cells? So sometimes, additional testing needs to be done. But if the ferritin levels are low and the iron levels are low, too, sometimes ferritin, less than about 45 to 50, it may be worth trying iron supplements to see if we can raise it.

But remember that blood transfusions, especially red blood cell transfusions, have iron in them, so if somebody is getting a lot of red blood cell transfusions, and they're also trying to eat too much iron in their diet and through supplements, they might actually end up with iron overload, not iron deficiency. And iron overload can also be toxic to the bone marrow, so we want to stay within what's a good sweet spot.

Cindy is asking about vital protein, and whether this would help. I'm not familiar with specifically, vital protein, and whether it will help skin and hair, but I would say that in general, I would prefer if you can get your protein through eating foods that are healthy than taking it from protein supplements. In general, if your hair or skin is looking unhealthy because of reduced protein intake, then that may be something that may help. But often, hair loss could be related to iron deficiency or biotin or zinc or vitamin D or other supplements, so it's important to look at those and see if any of those are related to it.

Also, off note, again, cancer patients, a little bit different, and older patients, a little bit different, but the RDA, or the recommended dietary allowance for protein is about 0.8 grams per kilo. And if we say that cancer patients or older patients need a little more, we can think about 1 to 1.2 grams per kilo body weight. When we calculate that, that's about 48 to 72 grams of protein per day. The US population on average eats double that protein every day, so is eating much higher protein intake than is necessary. Now, this may be different for a cancer patient who's not eating enough, or things like that, but I would encourage you to look at your diet and see if you think that overall, you're getting enough fiber, and whether you're focusing too much on protein and not getting enough fiber. Only about 5% of the US population gets enough fiber in their diet.

Thomas is asking about how much plant-based protein should be taken for someone to meet their daily macros. So I kind of answered that question, plant-based protein is not different from animal-based protein and the amount that you need to take in. Some people may say slightly higher amounts, and other experts say it doesn't matter, it's about the same. So in general, if you can get about 1 gram per kilo, maybe 1.2 grams per kilo, if you want to be on the higher end, then that's fine. One cup of beans, like pinto beans, will give you about 15 grams of protein, and about 10 to 15 grams of fiber. So if you are like the average US population, where you get 10 grams of fiber, you can just have one more cup of beans every day, and you will really reach the fiber recommended intake of about 25 to 30 grams.

So Sergio was asking about, are smoothies as nutritional as eating plants without whole plants? And I think that some researchers ... And I think the goal of nutrition has to be individualized to a person. So if it's somebody who's trying to gain weight, or who's losing weight and is not eating enough, but finds that they can take in a smoothie, then that's a really good way to get calories and take in healthy foods and fruits and vegetables, which may take harder time to chew or eat.

However, if somebody is trying to lose weight and is thinking about, okay, I want to have something where I'm actually losing weight, because I feel like I'm overweight or obese, then smoothies sometimes, because you can take in so many calories by drinking them faster, they can often sometimes lead to, you're taking in more calories than you want to. In general, if you're chewing the same amount as what you put into a smoothie, it's going to take you much longer than if you just drink a smoothie. So it depends, really, on the goals of the person, but smoothies can be part of a very healthy eating plan because they can allow you to take in the fruits, vegetables, fiber, and things like that, which somebody may be like, okay, I don't want to plan and eat a salad, or eat a side of something, but this allows you to.

Mavis is asking about any nutritional studies for myeloma patients with kidney involvement. I would actually love to do a study like that. As of now, we don't have a study open. I think there's a lot of data, like I said, on the National Kidney Foundation website. I've had cases of a few patients who've had really advanced kidney disease, and they were afraid that they would end up on dialysis. And we've talked about the National Kidney Foundation guidelines, I've shared them with them, and they have switched their diet to a more fiber-rich, plant forward diet, and seen improvement in their kidney numbers, or stabilization.

So it is possible in certain cases, but I have not seen a study like that done. There are some studies actually going on in healthy individuals and other populations, and I know that there's one study in New York taking place for kidney disease, and looking at nutrition and a plant-based diet, that's opening, I think in Brooklyn or Stony Brook, one of them. So there are studies like that, but we don't have one in myeloma, but would love to do it if we got funding for that.

I see a question from Jenny, could you say again how many plant foods? We talked about, ideally, 30 ... 30 was what that study with 10,000 individuals showed, but this was healthy individuals. So I think variety is quite important, because every food feeds different bacteria or the microbiome, so if we go into our comfort zones and are like, okay, I just like green beans, and I'm going to eat them every day as a side, and the same thing, banana and green beans, or something like that, then we're not getting the diversity. So try to go out of your comfort zone sometimes and pick things off the menu that maybe you wouldn't typically pick.

I see we are getting close to about half an hour, maybe we take a few more questions. There's a question about a keto diet and a Mediterranean diet, and any positive impacts from following these diets. So we wrote a nice paper in JAMA Oncology two years ago, this was Dr. [inaudible 00:28:59] and myself, and we looked at plant-based diets and ketogenic diets, and what is the evidence around them for cancer, and why do people study them, and how do we think about it for cancer? So that's a paper you can look at if you wanted to read more.

But in short, a ketogenic diet, I generally do not recommend it, and I'll explain to you why. If you are looking to lose weight fast in a short period of time, both a high fiber, plant-based diet and a ketogenic diet will help you achieve that, usually. But with the ketogenic diet, what a person is eating is an extremely low-carb diet, so they're kind of cutting out carbs almost completely and eating high fat, high protein. The good part about it is, when you cut carbs, you're cutting refined carbs, which are unhealthy, and so, that's why people feel better when they are on a low-carb diet.

But what is happening is, you're also cutting out fiber, and without fiber, there is a risk for increased cholesterol levels and cardiovascular risk, and that signal has been seen in some studies. Simultaneously, there's a really nice study from Kevin Hall from the NIH. He put patients in a metabolic chamber, so he basically said, you stay in this room for a few weeks, and we'll give you the food so we know exactly what you eat, and then we're going to see the effect on weight, on muscle mass, and things like that.

And this was a ketogenic diet compared to a plant-based, vegan diet. And what he saw was that both of them lost weight, but the ketogenic diet actually lost more water weight and muscle mass, but not fat mass, because they're eating high fat diet, mainly. Whereas the plant-based diet maintained muscle mass, but lost fat mass, and not as much water weight. So I think that it's important to think about how weight loss can be of different types. You want to maintain your muscle mass, and so, ketogenic diets actually maybe are associated with reduction in that.

Mediterranean diet is a healthy diet, but often, people, when we talk about vegan or vegetarian or Mediterranean, all of these are generally plant-forward diets, but I'm not really in favor of using those terms exactly when we are thinking about a healthy diet, always. Because somebody could be vegetarian, for instance, and say like, okay, I'm doing that, but they're eating a lot of fried foods and sugary foods, because that's all vegetarian, still, and junk food. So that doesn't end up being a healthy diet, and it could still be unhealthy.

Whereas we could have somebody who is an omnivore, and says, okay, I eat meat a few times a week or something like that, but I'm mostly eating fiber-rich foods, beans, nuts, seeds, grains, all of that. Now that is probably a healthier diet than a junk food diet, but even though it's vegetarian. And the same thing goes with Mediterranean. Often, I've seen people think that, okay, I'm doing a Mediterranean diet, but their diet is very heavy in dairy, chicken, and very low in the plant-based foods. The benefits of a Mediterranean diet come from the flavonoids and the plant-based foods in it, so if you're not getting enough of that, then you're not really following a true Mediterranean diet.

So in general, I would say it's easier if you can do a high-fiber, plant-based diet, whether it's high-fiber, plant-based, vegetarian, vegan, Mediterranean, high-fiber, plant-based omnivore, whatever works for you, but trying to get 80 to 90% of your calories from these fiber-rich foods is really going to help. And I see a question on FODMAP diet. I would say that a FODMAP diet is a very restrictive diet, and for all of you who don't know, a FODMAP diet is looking specifically at reducing certain foods that ferment different carbohydrates. And because of that, what ends up happening is, people are very much focused on very limited number of foods because they're avoiding a lot of things, and that in itself, long-term, can lead to nutritional deficiencies. So it's important if you have a medical reason where you feel like that's helping when you want to try it. It's okay to try it for a short period, but I wouldn't recommend it as a healthy diet forever, for the long period.

I see that JB is asking about remote second opinions or tele-visits. MSK does have a remote option of tele-visits, but it has to be within a state that I am licensed to practice in or have a license for, and so, that can sometimes be a bit challenging. As of now, I can do Florida, I can do New Jersey, New York, those are the main ones, but I think that we have colleagues on the Myeloma service who can do Connecticut and Pennsylvania, as well. Another way would be is that there is the office which allows it to be done outside of the billing or the insurance, but that can sometimes be expensive for patients because that would be through the institution.

I see a question about dairy. It's a question that ... Often, people who are vegetarian or eating more plant-based just assume that because dairy is vegetarian, dairy is healthy. But if you, again, think about what I'm talking about, plant-based versus animal-based foods, dairy is an animal-based food, so for all purposes, it has similar profile as an animal-based food. There's no fiber in dairy, whereas there's fiber in plant foods, so that's something to think about. However, dairy, the advantages mainly are that it has calcium, and if it's fermented dairy, then you have the benefit of it maybe being healthier for the microbiome.

But dairy is one of those foods that many people don't even know that they're lactose-intolerant. The statistics of the number of people who are lactose-intolerant, especially in populations that are non-white, is extremely high, some populations, it's as high as 70%. So many people have these digestion issues, and it's related to dairy, which they may not realize. So I think that if somebody really wants to eat dairy or continue, I think it has to be a small part of the diet, not the major source of the diet.

And in terms of dairy and cancer risk and things, there isn't a lot of evidence, and there's a little bit of data, but the data is more on hormonally-driven cancers, like prostate cancer. And that's the strongest evidence showing that there is in population studies, those who have high consumption of dairy have a higher risk of prostate cancer. Now, again, that's in large population studies, but it kind of makes sense because dairy is growth hormone for baby calves, in the sense of, it's food for baby calves to grow quickly. And so, there's a lot of growth hormones in it, as well, and so, this could be driving, also, the insulin, like growth factor levels that have been associated with increased cancer risk, but also, hormonally-driven cancers that depend on these hormones.

I see Gail has asked a question about intermittent fasting, maybe we take that, and then we take a question on blue zones, and then we could maybe stop after that. So the question from Gail was, intermittent fasting, and is that harmful? Again, I encourage you to think about for yourself, what stage of myeloma are you in, or your spouse, or whoever you are taking care of. Because if somebody is losing weight because of therapy or their disease, and then they do intermittent fasting and they severely reduce the calorie intake, then that could actually be maybe more detrimental or difficult to manage, especially also if they have appetite loss or things like that.

But simultaneously, if you think about, if a patient ... In terms of intermittent fasting, I think that it's physiologic to not be eating all day and eating within a window of timeframe. And given our now access to food and the convenience that never used to be there decades ago, we tend to ... We see food, we eat, we snack through the day. So if you can think about trying to regularize your meal times, it is going to be helpful for your gut health and overall health, because then you're activating the circadian rhythm and staying within good time windows.

So in general, I'd say at least a 12-hour window is a good healthy balance, like eating between 12 hours, and 12 hours, you're fasting. That's a good balance that can be achieved. Some people talk about intermittent fasting with a 16/8, so 8 hours of eating and 16 hours of fasting. I think that's a little bit more extreme, and I wouldn't recommend it for patients with cancer or other medical issues if they haven't really worked with a provider or someone on this. And intermittent fasting, in some studies, have worked, in terms of helping a person lose weight, because you're eating during a shorter time window. But if you eat the same amount of calories just in a smaller time window, it's going to be the same.

And often, people think because they're doing intermittent fasting, that means they can eat anything they want. And I wouldn't do that, because I think it's more important, the quality of the foods you eat, than just only focusing on within a time window. So ideally, I would suggest maybe within a 12-hour time window, and regularize your meal times, avoid snacking, and maybe pick three times a day. But if you are somebody who's losing weight, not got enough appetite, then you want to be snacking or eating enough to build that food intake, and that could be something like, snacking nuts are a good source of fats, healthy fats, and calorie dense, for somebody who's losing weight.

And then we said, Blue Zone diet healthy. And I think that's a good question, Cindy, because a Blue Zone diet, and many of you might have already watched this, there's a documentary series on Netflix, it's called Live to 100: Secrets of the Blue Zone. And Dan Buettner, who is the person who is behind the blue zones, and has written about it extensively, and he's written a book on it, too, goes around the world and tries to find the longest living populations in the world, and says, what's common between these populations?

So he finds six areas in the world that he feels are people who have lived the healthiest, longest lives, and what's common between these populations, and he puts that all into this documentary and his book. And what really stands out and is similar in these longest healthier living populations is regular physical activity, making sure that they're eating, really, a high fiber, plant-rich diet, having a community of friends and family, so there's a social connection in these communities. And really, everything they need to do for their daily living involves some walking or activities, like they have to climb uphill because they live on the hills, or for their work, they need to. So sedentary lifestyle isn't really great.

So with that, we'll wrap up, just a few things I wanted to bring up was that we are also fundraising for International Myeloma Foundation. So there are eight women physicians in Myeloma who are looking to ... We are going in July to trek in Peru and climb the Ausangate mountain range, which is very high altitude, so we're training for this. But we want to do this to support the Myeloma community, and I think that we'll share the link in the chat so you have some more information of what we're doing, and if that resonates with you, please share with others so we spread the word. And I also wanted to put the Linktree in the chat, which is basically a link to my social media handles, @urvishahMD, on Facebook, Instagram, LinkedIn, and Twitter. But also, it links to the research we're doing, and some of the talks I've given, so that could be easier for you to look at. It's all under that Linktree link.

The last thing I wanted to say was that I had done a talk in October last year for the Living Well International Myeloma Foundation program, and with that, we had a seminar, and that's on YouTube and on the IMF page. That's something you can also spend time where I go into in-depth, the research that's available around this. So with that, I'd like to just take a final moment to thank this year's Myeloma Action Month sponsors, 2seventy bio, Amgen, Binding Site, Bristol Myers Squibb, GSK, Johnson & Johnson, [inaudible 00:42:48] Farm, Pfizer, Regeneron, and Sanofi. I really thank all the over 100 viewers that have joined. We had more than 170 comments, so a lot of interaction, and really excited that there's so much interest in this topic. And for all of you who I couldn't get to your questions, hopefully we'll do this again sometime and try to answer questions then. Hopefully, it was helpful. Bye.